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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT IFIS 1601 E. HAZELTON AVE., STOCICTON, CA n „ Telephone (209) 466-6781 PERMIT EXPIRES 'I'YEAR FROM DATE ISSUED (Complete .in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. fr Job Address ��@�0�1 l e _ City Lot Size PM Owner's Na , , Address Phone T Contraclo A twli�Address (P `e'' y License No Phone TYPE OF WELL/PU NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION R< - f ` I� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL _PROBLEM AREA CONSTRUCTION SPECIFICATIONS_- ❑ Indusfrial C3 Open Bottom ❑ Manteca _ l�Dia. of,Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public P Other Ll Deka Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I Eastern Surface Seal Installed by s Repair Work Done ❑ Type of Pump H.P. - State Work Don_e_ Well Destruction ❑ Well Diameter Sealing Material (top 501, t r Depth Filler Material (Below 501 TYPE OF SLPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTIp I (No septic system permitted if public sewer is r available"within 200 feet.)--' sf Installation will serve: Residenw--_ 'Commercial--other Other Number of living-units:- Number of bedrooms Character.of soil-to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT."❑ r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE `❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS VI Depth Size Number SUMPS +Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS '© I hereby,certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the,following: "I certify that in the performance of the work for which this permit is issued, I shall not h employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that-in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." E The applic nt st c or all requir nspections. Complete drawing on rev rse side. Signed X Title: .._ '!/t�1/ t.� Date: 69 FOR DEPARTMENT USE ONLY kc I Application Accepted by Date_ r Area l Pit or Grout Inspection by Date Final Inspection by Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO �s00 �y + ER 13-24(REV,t/n 51 EH 1 4-26 Q�